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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "344" "paginaFinal" => "346" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Noemí López-Perea" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Noemí" "apellidos" => "López-Perea" "email" => array:1 [ 0 => "nlopezp@isciii.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Centro Nacional de Epidemiología, Instituto de Salud Carlos III, CIBER de Epidemiología y Salud Pública, Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿De nuevo el sarampión?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Measles is known for its extraordinary transmissibility and significant associated disease burden. It is estimated that a single case of measles is capable of infecting 12–18 susceptible people, and that the risk of becoming infected after an infectious person leaves an enclosed environment can persist for up to two hours. The risk of complications—including diarrhoea, otitis media, pneumonia or encephalitis—is not negligible, with one in five cases requiring hospitalisation. Children under 5 and those over 20 years of age are the age groups most at risk of complications. In 2018, there were around 140,000 measles-related deaths worldwide.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The fact that measles is a human-only disease, with no possibility of healthy carriers, coupled with the existence of an effective, affordable and widely accepted vaccine, makes it a good candidate for eradication.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The path to eradication necessarily involves elimination of the virus (absence of circulation in a given territory for at least 12 consecutive months), but due to its high transmissibility, in order to interrupt transmission, a vaccination coverage of over 95% with 2 doses of the MMR (measles, mumps and rubella) vaccine needs to be achieved at all geographic levels (from national to local).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The 1989 World Health Organisation (WHO) Assembly called for a reduction in measles morbidity and mortality and set its sights on the goal of eradicating the disease. Some 56 million lives have been saved<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> since 2001, especially in children under the age of 5. That year, WHO established the Measles Initiative with its founding partners (the American Red Cross, the US Centers for Disease Control and Prevention (CDC), the United Nations Foundation and UNICEF). In 2012, it was joined by rubella, becoming the <span class="elsevierStyleItalic">Measles and Rubella Initiative</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the years leading up to the COVID-19 pandemic (2018–2019), health authorities expressed deep concern about the alarming resurgence of measles in all WHO regions.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> WHO identified uneven or suboptimal vaccination coverage and travel-associated measles importations as key factors in the relentless increase of cases and outbreaks.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To ensure that each birth cohort is adequately vaccinated, gaps in population immunity must be minimised.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Particularly vulnerable groups of people, such as those displaced by humanitarian crises, victims of war or violence, as well as people reluctant to receive the MMR vaccine, could accentuate these immunity gaps.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Today, measles remains one of the leading causes of morbidity and mortality in the world, as evidenced by the relentless increase in outbreaks and cases<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and continues to pose a challenge in meeting the goal of eradication. The three main pillars that explain the successive failures to achieve eradication are the difficulty in achieving and maintaining high vaccination coverage, the lack of quality surveillance systems, and the weakness of rapid response mechanisms to measles cases or outbreaks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The COVID-19 pandemic also led to a sharp decline in the reporting of measles cases worldwide due, in part, to lockdowns and restrictions on movement, physical distancing measures and the use of face masks. However, the pandemic also had an impact on countries' own health systems, preventing or hindering access to resources such as routine vaccination. This has led to gaps in vaccination coverage among under-fives, which is fuelling measles outbreaks in the WHO European Region, requiring urgent action.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In 2000,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> after having achieved coverage of over 95% with the first dose of MMR, Spain joined the measles eradication initiative proposed by WHO’s European Regional Office in 1998. This was done after the vaccine had been part of the schedule for almost 20 years (1981) and measles rates were in clear decline (<1/100,000 inhabitants since 1999), especially after the incorporation in 1995 of the second dose.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although our country has continued to experience measles outbreaks,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and some of significant magnitude (2010–2012), the virus has not been endemically circulating since 2014. WHO certified measles eradication in Spain in 2017, after 36 consecutive months without endemic circulation of the virus, and has ratified it every year since.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The COVID-19 pandemic affected Spain in a similar way to neighbouring countries: first with an abrupt decrease in measles case reporting after the implementation of lockdown measures in 2020, followed by only 2 cases reported in 2021 and 1 in 2022, and most recently with an increase to 14 cases in 2023;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9–11</span></a> the latter due to the resumption of international travel and the removal of the aforementioned measures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">During the pandemic period, national vaccination coverage with the first dose of MMR vaccine was barely affected, despite the pressure on the health system, and has remained above 95%. However, some autonomous communities (ACs) recorded coverage below 90% in 2021. For the second dose, the decline in coverage at the national level was even more pronounced and the 95% target, already difficult to achieve, was even further away. Several ACs launched campaigns to recruit those who had not been vaccinated, and by 2022 coverage was similar to that recorded before 2020.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The 2nd Spanish Seroprevalence Survey published in 2021, but referring to data from 2017 and 2018,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> identifies cohorts born between 1988–1997 (20–29 years old at that time) as particularly susceptible to measles (measles seroprevalence of 86.9%), and relates this to a possible loss of antibody titres associated with the absence of virus circulation and the fact that these cohorts have low vaccination coverage with two doses. It is also important not to lose sight of the traditionally susceptible cohorts who were born in the years when measles circulation began to decline and who were not vaccinated or only partially vaccinated (1972–1995). The Survey indicates that the population born before 1978 has a seroprotection rate of over 98.0%.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The epidemiological reality of the post-eradication era, together with the need to align our objectives and quality indicators with those required by WHO, led to the implementation of the Strategic Plan for the Elimination of Measles and Rubella in Spain (2021–2025) in 2021.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> At this point, the highest possible certainty in the diagnosis of each suspected measles case is required. The changes to the laboratory algorithms in the Strategic Plan attempt to take into account the diagnostic complexity of measles in countries undergoing eradication, such as those cases whose clinical manifestations are less severe because they have been properly vaccinated (modified measles).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Genomic testing has become an important tool for the traceability and detailed characterisation of transmission chains,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in addition to providing evidence to WHO that measles is not endemic in Spain.</p><p id="par0070" class="elsevierStylePara elsevierViewall">One of our country's strengths in achieving measles eradication is that we have achieved and maintained a high coverage with the first dose of MMR. In Spain, there is a high level of community acceptance of this vaccine, as evidenced by the fact that cases of measles associated with anti-vaccination attitudes are negligible;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> unlike what happens in some countries, where distrust of the COVID-19 vaccine has been transferred to long-established vaccines, such as MMR.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Another of our strengths is that we have a consolidated, high-quality, surveillance system: upon detection of a suspected measles case, the necessary mechanisms are activated for the diagnosis and control of possible secondary cases, thus interrupting transmission at an early stage.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However, circumstances such as modified measles, the spread of the virus in health care settings and cases among correctly vaccinated individuals<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> may pose a challenge to maintaining the eradication situation in our country. It is also worth remembering that second dose coverage has never reached 95% since its introduction in 1995 in Spain, and that this weakness should be considered a priority in order to have all cohorts correctly vaccinated with 2 doses. One of the paradoxes of measles eradication is the potential difficulty for medical staff to identify suspected cases: the small number of cases limits clinical experience.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Clinicians are the first link in the system and their awareness and commitment is paramount to the successful eradication of this disease.</p><p id="par0085" class="elsevierStylePara elsevierViewall">As the WHO states in its Strategic Framework 2021–2030,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> measles outbreaks can be seen as indicators of health inequalities <span class="elsevierStyleItalic">per se</span>, like a canary in a coal mine. On the other hand, they can also be seen as opportunities to identify gaps in immunisation programmes and primary health care systems.</p><p id="par0090" class="elsevierStylePara elsevierViewall">There is an inescapable need to strengthen primary health care as the first point of access to the health system, as an element of health education (health workers' advice is essential for people to make health decisions, such as whether to be vaccinated), and as a direct source of knowledge about the measles-susceptible populations they serve. The traditional lifelong vaccination schedule<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> allows the full schedule to be received, taking advantage of every contact with the system and thus helping to reduce immunisation gaps in the population.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The risk of measles cases and outbreaks in our country will persist as long as the virus continues to circulate globally and population immunity is insufficient. Importation of cases is inevitable due to movement of people, but it is essential to achieve and maintain coverage above 95% with 2 doses at all geographical levels to prevent secondary transmission.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0100" class="elsevierStylePara elsevierViewall">None to be taken into account.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">The author declares having received no funding for this work.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The author declares no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Measles and rubella strategic framework 2021–2030" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "World Health Organization" ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2020" "editorial" => "World Health Organization" "editorialLocalizacion" => "Geneva" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://iris.who.int/bitstream/handle/10665/339801/9789240015616-eng.pdf?sequence=1" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Vuelve el sarampión?" 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Journal Information
Vol. 163. Issue 7.
Pages 344-346 (October 2024)
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Vol. 163. Issue 7.
Pages 344-346 (October 2024)
Editorial
Measles again?
¿De nuevo el sarampión?
Noemí López-Perea
Centro Nacional de Epidemiología, Instituto de Salud Carlos III, CIBER de Epidemiología y Salud Pública, Departamento de Medicina Preventiva y Salud Pública, Universidad Autónoma de Madrid, Madrid, Spain
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